Risk of Reye Syndrome with NSAIDs in Children with Viral Infections
Ibuprofen and other non-aspirin NSAIDs do not carry a risk of Reye syndrome in children with viral infections, while aspirin (acetylsalicylic acid) has a well-established association with Reye syndrome and should be avoided in children and adolescents with viral illnesses. 1, 2, 3
Understanding Reye Syndrome
- Reye syndrome is a rare but potentially fatal biphasic illness characterized by acute encephalopathy and fatty infiltration of the liver that typically occurs following a viral illness (particularly influenza or varicella) 4
- The syndrome manifests with protracted vomiting and neurologic changes that typically begin 3-5 days after the viral prodrome, just when the child appears to be recovering 4
- Mortality rates from Reye syndrome can be as high as 30-40% due to brainstem dysfunction 5
Aspirin and Reye Syndrome Connection
- There is a well-established association between aspirin use during viral illnesses and the development of Reye syndrome in children and adolescents under 18 years of age 6
- Since 1986, the FDA has required warning labels on all aspirin products regarding this association 4
- The incidence of Reye syndrome has decreased dramatically since public awareness campaigns about avoiding aspirin in children with febrile illnesses began 4, 3
- The risk of Reye syndrome appears to decrease with age, becoming extremely rare by late adolescence 3
NSAIDs and Reye Syndrome
- Non-aspirin NSAIDs such as ibuprofen have not been associated with Reye syndrome 3, 7
- The CDC and other health authorities specifically recommend avoiding aspirin in children with viral illnesses, but do not extend this warning to other NSAIDs 1, 2
- For relief of fever in children with suspected viral illnesses, other antipyretic medications such as acetaminophen or non-aspirin NSAIDs are recommended instead of aspirin 1
Clinical Recommendations
- Acetaminophen and ibuprofen are the preferred antipyretics for children with fever or viral syndromes 7
- Children aged <4 years should not receive over-the-counter cold medications without consulting a healthcare provider first 1
- Aspirin use in children should be limited to specific conditions where it has proven benefit, such as Kawasaki disease and juvenile arthritis 3
- In Kawasaki disease, where aspirin is indicated, children should receive annual influenza vaccination if on long-term aspirin therapy 1
- Parents of children on aspirin therapy should be instructed to contact their physician promptly if the child develops symptoms of or is exposed to influenza or varicella 1
Special Considerations
- For children with Kawasaki disease who require aspirin but are exposed to influenza or varicella, some physicians substitute another antiplatelet medication for aspirin temporarily 1
- Children and teenagers (6 months-18 years) receiving long-term aspirin therapy are considered a high-risk group for influenza complications and should receive annual influenza vaccination 1
- The main risk to children taking NSAIDs like ibuprofen is dosage errors resulting in overdose, not Reye syndrome 1
In conclusion, while aspirin should be avoided in children with viral illnesses due to the risk of Reye syndrome, non-aspirin NSAIDs like ibuprofen do not carry this risk and can be safely used as antipyretics in children with appropriate dosing.